1891892634 NPI number — DJKL INC

Table of content: (NPI 1891892634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891892634 NPI number — DJKL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DJKL INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARION FAMILY PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891892634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1581 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24354-4317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-783-7184
Provider Business Mailing Address Fax Number:
276-783-3839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1581 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24354-4317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-783-7184
Provider Business Practice Location Address Fax Number:
276-783-3839
Provider Enumeration Date:
09/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RATLIFF
Authorized Official First Name:
KRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
276-783-7184

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0201002433 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8514097 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2105235 . This is a "PK" identifier . This identifiers is of the category "OTHER".